In another blow to AHIP's members, the Final 2015 Letter sets a higher standard for the percentage of essential community providers that insurers must include in their provider networks. For 2014, provider networks operating on the exchanges had to include 20% of essential community providers present in the network's geographic area. In 2015, provider networks will be required to include 30% of essential community providers.
In its Feb. 25 comments submitted to federal regulators, AHIP raised several objections to the 30% standard, including the short time frame to adjust to the new standard, the apparent emphasis on network size over other considerations such quality and local market dynamics, and the "troubling" ability of CMS to review payment rates and offers to prove good faith, which could reveal "sensitive competitive information."
More change on 2015 horizon
In a change that adds bite to regulation of the public exchanges, CMS will not be continuing the "good faith enforcement safe harbor" given to health plans in 2014, exposing insurers to possible civil fines.
According to the Final 2015 Letter: "CMS acknowledged the transitional nature of the 2014 benefit year, and agreed not to impose civil money penalties or decertify QHPs for non-compliance with certain Marketplace requirements if the QHP issuer has made good faith efforts to comply with applicable requirements. CMS expects that by 2015, issuers will have gained more experience operating in the [public exchange] environment and/or will be more familiar with the Marketplace requirements."